A wheel failure that led to a train derailment, damaging 590 m of track, likely originated from a crack on the tread surface, the ATSB has found.

On 28 August 2015, a Pacific National fully loaded coal train MB520 departed from Maules Creek, NSW destined for Port Waratah, NSW. Shortly after passing Ardglen and descending the grade towards Pages River, a wheel failure occurred on the leading right hand wheel on the 19th wagon. This led to the wheel moving off the wheel seat towards the centre of the axle. The bogie rotated causing the other wheels on the bogie to derail. The train continued travelling until a damaged inter car brake cable activated the train’s brakes. There were no injuries, but the derailment caused damage to over 590 metres of track including 963 sleepers.

What the ATSB found

The ATSB investigation found that the derailment was caused by a wheel failure. A metallurgical analysis conducted after the derailment found that the wheel had multiple cracks in the wheel rim; one crack extended from the rim to the boss of the wheel. This likely originated from a transverse thermal crack on the wheel tread surface. Thermal cracks of this type are generally associated with high thermal input under service brake conditions.

An increasing level of wayside alerts starting a month before the derailment indicated the likelihood of the fault being present then. Despite the increasing impact level readings, no immediate action was taken to inspect the wheel before it eventually failed.

It was found that the wheel inspection processes were not effective in detecting surface damage or cracks. The failed wheel was approaching the end of its service life with a rim thickness of 25 mm. This low rim thickness increases propensity to thermal distortion and is likely a significant factor into the thermal crack formation and propagation that occurred.

At the time of writing this report there have been seven reports of fractures detected in wheels, within a 3-year period, on Pacific National coal wagons in NSW. Three occurred before the derailment with the first incident on 31 May 2013. Three more fractured wheels were identified within a two-month period after the derailment. Following the first three wheel failures internal reports recommended changes to reduce the risk of wheel defects. Only limited action was taken by the operator prior to the derailment on 28 August 2015.

Since the derailment, the rollingstock operator has advised that they have established a process to remove wheels considered to be at greater risk of fracture. To this end, they have implemented a program to remove wheels with a rim thickness under 25 mm. Pacific National also intends to improve their internal standards to include revised criteria and actions for thin rims and wheel impacts.

Safety message

Rollingstock operators with heavy haul wagons using wheels near the end of their service life should be aware of the increased risk of wheel failure due to cracking. They should ensure that wheel inspection and maintenance programs include systems and techniques for detecting and assessing wheel defects with the potential to lead to cracking. These systems and techniques should be validated to ensure they are effective to detect such defects.

Read the final report: Derailment of freight train MB520, Pangela, New South Wales, on 28 August 2015

• Fatigue may have contributed to the first officer not hearing the captain’s ‘gear up’ call.

On the evening of 4 December 2014, a Saab Aircraft Co. 340B aircraft, registered VH-ZRJ and operated by Regional Express, was on a scheduled passenger service from Sydney to Narrandera, New South Wales. After take-off from runway 34 Left the crew inadvertently did not retract the landing gear. The crew later identified this and instinctively retracted the gear whilst the aircraft was above the maximum landing gear retraction speed.

The ATSB found that at the time of the occurrence the first officer (FO) was experiencing a level of fatigue that affected performance. However, the FO’s ability to self-assess their level of fatigue was impeded by a lack of training and objective tools to determine their suitability to operate.

The ATSB also found that the FO did not recall hearing the captain’s ‘gear up’ call, which meant that the gear was inadvertently not retracted. The factors that influenced this omission and its non‑detection included both crew focusing on departure procedures and the local weather, and the crew likely expecting that the landing gear was retracted as normal.

The crew detected the error when conducting the climb checklist. As this checklist was designed to confirm the configuration of the aircraft, the time that it was conducted coincided with a time when the aircraft’s speed was above the maximum gear retraction speed. Therefore, there was an increased risk that crew would react to the unexpected gear position before slowing the aircraft.

In March 2013, the Civil Aviation Safety Authority released new rules on fatigue management for flight crew. At the time of the occurrence, air operators that already held, or had applied for an air operator’s certificate after April 2013, had until April 2016 to transition to the new fatigue management rules. Consistent with this timeline, Regional Express was planning for their transition to meet those requirements at the time of the occurrence. In November 2015, this deadline was extended by the Civil Aviation Safety Authority to May 2017.

Safety message

This occurrence demonstrates some of the factors that increase the risk of making and not detecting errors of omission, particularly actions prompted by verbal cues. The use of a checklist helps identify errors, but they are most effective in this regard, if they are timed to be conducted before approaching aircraft limits.

Further, while this occurrence highlights the difficulties associated with assessing fatigue, operators and crew share responsibility for managing the risk of fatigue. Operators can reduce fatigue risk by providing crew with adequate rest opportunity, comprehensive training in fatigue management, and tools designed to support objective self-assessment of their alertness. Crew can then use the knowledge and tools to help identify when fatigue is present and may affect safety.

Read the final report: Landing gear retraction overspeed involving a Saab 340B, VH-ZRJ, Sydney Airport, New South Wales, on 4 December 2014

While repositioning, the pilot commenced lifting this Bell 206L-1 helicopter into a hover from a temporary helipad. It started rolling about the right skid until the main rotor blades struck the ground.

On 2 November 2013, the pilot of a Bell 206L-1 helicopter, registered VH-VDZ, was conducting passenger-carrying charter operations between Olympic Park oval and Flemington Racecourse, Melbourne, Victoria. At about 1830 Eastern Daylight-saving Time, the pilot prepared to reposition the helicopter from one of the temporary helipads at Olympic Park. There were no passengers on board.

As the pilot lifted the helicopter into a hover it started rolling about the right skid, which was in contact with the ground. The helicopter rapidly rolled further right until the main rotor blades struck the ground. A large amount of main rotor and other high energy debris was released from the helicopter and impacted a nearby marquee, a number of vehicles and a helicopter on an adjacent helipad. The pilot sustained minor injuries.

The ATSB found that the pilot did not identify and react to the helicopter’s right-skid low attitude in sufficient time to prevent the helicopter rolling over. In addition, an unsecured ballast bag was positioned on the left front floor of the helicopter, increasing the risk of injury to occupants. Further, the helicopter’s dual flight controls were removed to facilitate the flights. The person who removed the controls did not have the training or authorisation to conduct the maintenance procedure. The left cyclic stub cover was not installed, leaving the stub exposed. This resulted in the potential for the ballast bag to inhibit movement of the pilot’s cyclic control due to fouling of the left cyclic stub.

The ATSB identified safety issues relating to the availability of first aid and emergency response equipment at the oval and the proximity of the helipads to the perimeter fence and public access areas. Each increased the risk of injury to bystanders in the event of an accident.

For subsequent operations at the Olympic Park oval for the remainder of the event, the charterer positioned firefighting equipment at each helipad and first aid equipment was made available nearby. In addition, the helipads were repositioned further from the passenger marquee, and passengers were not loaded or unloaded if helicopters were in the process of landing or taking-off from adjacent helipads. Operations at the Olympic Park oval ceased following the 2013 carnival.

Safety message

This accident highlights the importance of coordinated control inputs by pilots during lift-off to control any roll, and if necessary smoothly lowering the collective in coordination with cyclic input to re‑establish the helicopter’s weight evenly on the ground before any roll becomes excessive. The importance of properly securing any equipment, particularly if stowed in aircraft cockpits, and of the correct removal and re-fitting of dual flight controls to prevent any obstruction or fouling of the controls is emphasised.

In addition, this accident is a reminder of the risks involved when operating helicopters in public areas. Although the likelihood of a helicopter accident on the ground that results in injuries was found by the ATSB to be low, in the event of an accident, high energy rotor and other debris can travel large distances. Where possible, operators should consider larger distances around helicopter landing areas, in particular when operating close to public areas.

Read the final report: Collision with terrain involving Bell 206L helicopter, VH-VDZ, 13 km south-east of Essendon Airport, Victoria, on 2 November 2013

The original forecast at the time of departure for the intended destination of Adelaide, did not predict fog. During the flights, fog formed at Adelaide, preventing a normal landing. Both crews considered conducting an auto land at Adelaide but with better weather expected at Mildura they both chose to divert, only to find deteriorating conditions there too had left them with limited options.

As a result, both crew landed below minima at Mildura.

On 18 June 2013, two Boeing 737 aircraft, VH-YIR operated by Virgin Australia Airlines Pty. Ltd. as Velocity 1384 and VH-VYK operated by Qantas Airways Ltd. as Qantas 735, were on scheduled flights to Adelaide, South Australia.

On nearing Adelaide, the forecast improvement in weather conditions had not occurred and as a result, both aircraft commenced a diversion to Mildura, Victoria. Upon arrival at Mildura, the actual weather conditions were significantly different to those forecast, in particular with visibility reduced in fog.

The flight crew of Qantas 735 conducted an instrument approach and landed below minima. The flight crew of Velocity 1384 also conducted an instrument approach and landed below minima in fog and with fuel below the fixed reserve.

The ATSB found that the weather deterioration at Adelaide did not appear on the forecast when both aircraft departed their respective ports and furthermore the forecast duration of the fog in the later, amended forecast showed a clearance time earlier than actually occurred. This meant that Qantas 735 continued to Adelaide with the expectation that the fog would clear prior to their arrival, which did not occur. It also influenced the decision making of the Virgin Australia flight watch personnel, who did not pass this weather to the flight crew of Velocity 1384.

In relation to the weather at Mildura, the ATSB found that the deterioration was significantly worse than originally forecast. This resulted in the need for both Qantas 735 and Velocity 1384 to land in conditions that were below minima. The ATSB identified that both flight crew uploaded sufficient fuel for the originally-forecast conditions in accordance with their operators’ fuel policy and the Civil Aviation Safety Authority requirements.

The ATSB also found that in certain weather patterns and at certain locations, fog is both rare and difficult to forecast reliably.

In addition, the ATSB noted that the industry expectation for the provision of flight information services was not aligned with that provided by Airservices Australia (Airservices). Further, it was identified that in certain circumstances, pilots will not be made aware of a deterioration of weather at an airport that has an Automatic Weather Information Service or other Automatic Broadcast Service. These services did not provide for the recognition and active dissemination of special weather reports (SPECI) to pilots, thereby not meeting the intent of the SPECI alerting function provided by controller-initiated flight information service.

In response to this occurrence, Airservices advised that they would work with the Bureau of Meteorology to explore feasible options to provide information on significant deteriorations in weather conditions to address the very high frequency radio range limitations of the automated broadcast services. In the meantime, Airservices has updated the Manual of Air Traffic Services to ensure dissemination of weather information from locations with an Automatic Weather Information Service should that service be unavailable.

The Bureau of Meteorology advised of various system changes and improvements in response to this occurrence. This included to equipment used in forecasting.

Virgin Australia Airlines Pty. Ltd. (Virgin) advised of a review and benchmarking exercise as part of its examination of this occurrence. This resulted in enhancements to Virgin’s flight planning and flight following policies, re-organisation of the flight following section and expansion of communication infrastructure across the Virgin fleet. In addition, Virgin’s pilot weather requirements have been clarified and enhanced.

In response to this occurrence the ATSB issued a safety recommendation to Airservices. This recommended that Airservices, as the issue owner, work in collaboration with the Bureau of Meteorology to instigate a system change to reinstate the alerting function of SPECI reports currently not available through an Automatic Broadcast Service.

Safety message

Pilots are reminded of their responsibility for collecting all relevant information to support in‑flight decision making. This includes weather and operational information for the destination, which should be considered prior to a decision point or point of no return.

It is important that pilots understand what will be provided under Airservices’ provision of flight information service and that they are also able to request weather and operational information from air traffic control. In addition, pilots should note the potential benefits of informing the controller of a non-normal situation. These include increased monitoring and support as required and the potential to reduce pilot workload in stressful situations.

Read the final report: Landing below minima due to fog involving Boeing 737s, VH-YIR and VH-VYK, Mildura Airport, Victoria, on 18 June 2013

Late afternoon glare and light refraction affected the pilot’s vision and depth of field, with tragic results.

On 28 May 2015, the pilot of a Robinson 22 helicopter, registered VH-HRW, was engaged in aerial mustering operations about 64 km north-north-east of Mitchell, Queensland. Late in the afternoon the helicopter’s tail rotor struck the branch of a 7 m‑high dead and defoliated tree, the pilot lost control of the helicopter and it collided with terrain. The helicopter was destroyed and the pilot, the sole occupant, was fatally injured.

The ATSB found that the pilot was appropriately qualified and flying due west in a serviceable helicopter at low level. The sun was to the north-west and about 13°–15° above the horizon at that time. The helicopter’s tail rotor collided with the upper branch of an isolated tree. That collision separated a portion of the tail rotor blades, leading to the remainder of the tail rotor and the helicopter’s horizontal and vertical stabilisers and tail rotor gearbox also separating. The pilot could not control the helicopter and it collided with terrain.

Given the conditions, it is likely that sun glare and the darkened backdrop of a tree-lined dry creek bed affected the pilot’s vision and perception, and therefore ability to identify the isolated tree. Despite the pilot wearing a helmet that was fitted with sun visors, the ATSB could not determine whether the visors were lowered at the time. In any event, it is likely that the pilot did not see the tree, or misjudged its height and/or its distance from the approaching helicopter.

The ATSB did not identify any pre-existing mechanical defects and established that, at the time of the accident, the helicopter was likely serviceable. The helicopter was fitted with a three‑point safety harness and bladder‑type fuel tanks. These tanks decrease the risk of a post‑impact, fuel‑fed fire. Despite these additional safety features, and the safety benefits possible from the pilot wearing a helmet, the accident was not survivable due to impact forces. A number of unrestrained items in the cabin increased the risk of injury as a result of those forces.

Safety message

Low-level aerial mustering operations are an inherently high-risk activity. When conducting this type of operation, pilots need to consider the environmental conditions as part of their flight planning and operational risk assessment. The ATSB and the Civil Aviation Safety Authority have released a number of publications illustrating the risks associated with this type of operation that provide guidance and strategies for mitigating those risks.

Read the final report: Collision with terrain involving Robinson R22, VH-HRW, 63 km north-north-east of Mitchell, Queensland, on 28 May 2015

A wasp nest obstructed the Captain’s pitot probe after a short layover in Brisbane.

On 21 November 2013, after a flight from Singapore, an Etihad Airways Airbus A330, A6-EYJ landed at Brisbane airport and was taxied to the terminal. Approximately 2 hours later, the aircraft was pushed-back from the gate for the return flight to Singapore.

The captain rejected the initial take-off attempt after observing an airspeed indication failure on his display. The aircraft taxied back to the terminal where troubleshooting was carried out, before being released back into service.

During the second take-off roll, the crew became aware of an airspeed discrepancy after the V₁ decision speed and the take-off was continued. Once airborne, the crew declared a MAYDAY and decided to return to Brisbane where an overweight landing was carried out.

Engineering inspection after the overweight landing found that the Captain’s pitot probe was almost totally obstructed by an insect nest, consistent with mud-dauber wasp residue.

Engineering inspection after the overweight landing found that the Captain’s pitot probe was almost totally obstructed by an insect nest, consistent with mud-dauber wasp residue. The pitot obstruction had occurred during the 2 hour period that the aircraft was on the ground at Brisbane and was not detected during troubleshooting after the initial rejected take-off.

The aircraft operator has changed its policy on the use of pitot covers. They are now required to be used on all transits at Brisbane Airport, regardless of ground time.

The aircraft manufacturer has amended its maintenance troubleshooting manual to increase the likelihood that a blocked pitot probe will be detected.

The airport operator has extended its wasp inspection and eradication program and reviewed and updated its Wildlife Hazard Management Plan.

In addition, CASA has drawn attention to the safety implications of mud wasp activity through several publications.

Safety message

Operators can minimise the risk of pitot probe obstruction by consistently using pitot covers even during short transit periods.

Standard operating procedures include the cross-checking of airspeed during the take-off roll. These checks are an important last line of defence in preventing an aircraft from becoming airborne with airspeed indication problems.

Read the final report: Air data system failure involving Airbus A330-243, A6-EYJ, near Brisbane Airport, Queensland, on 21 November 2013

Two large ships’ sterns broke away from their berths when a common bollard holding their stern lines failed, damaging a rail bridge and a third vessel.

On 17 August 2014, Grand Pioneer (Figure 1) and AAL Fremantle (Figure 2) broke away from their berths when a thunderstorm passed across the Port of Fremantle. A bollard on the wharf holding both ships’ stern lines failed, most likely after Grand Pioneer’s vehicle ramp contacted it. AAL Fremantle contacted a ship at an adjacent berth, and parts of the Fremantle Rail Bridge nearby.

The ships were berthed again with tug assistance. The ships had suffered minor damage. The rail bridge, however, was closed for 3 weeks for inspection and repairs to track alignment and other non-structural damage.

Figure 1: Grand Pioneer

Source: Marcus, Shipspotting

Figure 2: AAL Fremantle

Source: Australian Transport Safety Bureau

The ATSB investigation concluded that Grand Pioneer moved off the berth slightly as the tension in its mooring lines increased, in response to the high winds associated with the passing thunderstorm. It is likely that its vehicle ramp then made contact with the bollard that held the stern lines of both ships. As a result of the contact, the bollard broke away from the wharf.

The investigation found that Fremantle Port Authority’s (Fremantle Ports) examination of the risks associated with a ship contacting the rail bridge contained limited analysis on keeping ships alongside in adverse weather, particularly at berths 11 and 12 where the wind is predominantly on ships’ beams. There was also no analysis of the means to assist a ship that got close to Wongara Shoal and the rail bridge.

The ATSB also found that Fremantle Ports’ adverse weather procedures were triggered only by specific Bureau of Meteorology (BoM) forecast categories and terms. There was no guidance for vessel traffic service (VTS) officers to take action based on actual weather conditions, or other weather terms used in BoM forecasts.

Another investigation finding was that BoM’s marine forecast at the time of the incident did not describe expected wind speeds using recognised marine terms, such as ‘gale force’. Further, the forecast title understated the wind speeds expected.  

Fremantle Ports has put into service 12 ShoreTension devices in the inner harbour. These devices maintain a constant tension in a mooring line to assist keeping a ship alongside its berth.

The port has subscribed to a customized weather prediction service for its area, and upgraded its weather station and VTS equipment to enhance monitoring. The VTS officers have been trained to use the new and upgraded equipment. The port has updated its ship weather warnings to include a broader range of meteorological terms and descriptions.

Fremantle Ports has also revised its weather warning distribution list to include the manager of the rail bridge, the Public Transport Authority (PTA). The port and the PTA have established direct, high level, points of contact with communication processes in place to manage any emergencies that could involve the rail bridge.

The BoM safety action includes undertaking to use standard terminology in marine forecasts and implementing a formal process to consult stakeholders to better identify and meet their needs.

Safety message

When analysing the risks to a port’s operation, its operator needs to consider the risk controls to avoid a serious incident as well as the recovery controls in case an incident does occur.

Read the final report: Breakaway of Grand Pioneer and AAL Fremantle, Fremantle, Western Australia, on 17 August 2014

Metal fatigue caused a welded boss on the No.2 engine to give way, resulting in a fuel-fed fire that was brought under control by the flight crew.

On 29 April 2014 an AVRO 146-RJ100 aircraft, registered VH‑NJI and operated by Cobham Aviation Services Australia (Cobham), was on a charter flight to Barrow Island Airport from Perth Airport, Western Australia. The aircraft sustained a mechanical failure of the No. 2 engine shortly after take-off that resulted in an in-flight fuel-fed engine fire.

The flight crew extinguished the engine fire by shutting down the No. 2 engine and activating the fire suppression system. The aircraft was flown back to Perth Airport, having sustained significant damage to the No. 2 engine and cowling. There were no injuries.

The Honeywell International Inc (Honeywell) LF507-1F (LF507) engine has four combustion liner locating pin welded bosses (welded boss) in the combustor turbine module (CTM) combustor housing (housing). The ATSB found that the welded boss located at the 2 o’clock position had cracked and fractured adjacent to the weld as a result of fatigue. The boss separated from the housing, allowing high-pressure combusting fuel to escape radially through the CTM housing, burning through the engine cowling.

The ATSB found that the normal scheduled visual inspection of the housing, which was designed to find cracks before they developed into a fracture, was ineffective in this case.

The ATSB also found that localised grinding of the inner and outer surfaces of the CTM housing, adjacent to the welded boss, had reduced its wall thickness from 0.050 to 0.035 inches. The reduced wall thickness increased local stresses and hence the likelihood of crack formation. The crack accelerated at an unpredictable rate until penetrating the full thickness of the housing. It is likely that the grinding was associated with a weld repair conducted during a CTM heavy maintenance visit. The grinding repair was not an acceptable repair to Honeywell for returning the component to the original design strength.

Finally, the ATSB found that the normal scheduled visual inspection of the housing, which was designed to find cracks before they developed into a fracture, was ineffective in this case. This was because the reduced wall thickness invalidated the original crack growth rate predictions.

In response to this occurrence Cobham proactively inspected all of their LF507 engines, focusing on the welded bosses. Of those engines, one spare engine had grinding at one of the welded bosses, similar to the occurrence engine, and was withdrawn from the availability pool. Although no cracking was found at the combustion liner location pin welded bosses, Cobham did find seven cracks at the location of the ignition bosses that had not been previously identified. These cracks were managed in accordance with the Honeywell maintenance manual.

Honeywell also instigated several actions in response to this occurrence. These included amendment of the LF507 engine maintenance and overhaul manuals to address crack limits and weld repair specifications, and the issue of a Service Bulletin to alert operators of possible welded boss cracking.

Safety message

This occurrence highlights the importance of repairing aircraft components in accordance with the manufacturer’s specifications and ensuring that the repair meets the design intent of the manufacturer.

Read the final report: In-flight engine fire involving AVRO 146-RJ100, VH-NJI, departing Perth Airport, Western Australia, on 29 April 2014

• A collision between a ute and aircraft shows why good communications is essential in all aircraft operations.

On 17 September 2015, the pilot of an Air Tractor 502B aircraft, was conducting aerial application (spraying) operations on a property about 23 km to the west of Hay Aerodrome, New South Wales.

As per normal procedure, while en route to the spray application area, the pilot made a broadcast on UHF Channel 25 advising that spraying operations were about to commence, and also, the area where that would occur. UHF Channel 25 was monitored by employees on the property, and used for general communications.

The driver of a tractor operating in the southern part of the spray application area responded to the pilot’s broadcast. The pilot advised the tractor driver that they would be able to safely continue in that southern area for about another hour.

After a short time, the pilot departed the spray application area and reloaded the aircraft with more chemical mixture at a nearby property. The pilot then returned to the spray allocation area at about 1130. This time, the pilot did not make another UHF broadcast, but noted that the tractor was now in transit between work areas, with a Toyota Hilux Double-Cab utility vehicle following closely behind.

At about 1145 as the pilot was conducting a spray run to the east, the pilot reported seeing the Hilux turn onto an irrigation channel crossing ahead of the aircraft. However as the vehicle appeared to be slowing to a stop short of the intersection, the pilot assumed the Hilux driver had seen the aircraft, so continued with the spray run. After checking the spray nozzles on the wings, and the spray pressure gauge, the pilot initiated a short climb to clear the raised channel bank.

The pilot then sighted the Hilux on the highest part of the channel bank. The pilot immediately ceased the spray and initiated a steeper climb. During this attempt, the left wheel of the aircraft struck the tray headboard of the Hilux from behind.

The pilot radioed for assistance for the driver and flew to a nearby property to land.

As a result of this occurrence, the agricultural company have revised some procedures, roles and responsibilities.

This accident highlights the importance of effective communication by all parties involved with aircraft operations.

ATSB Research and Analysis Report AR-2015-031 Aerial application safety: 2014 to 2015 year in review, provides statistical data regarding aerial application accident rates, and summarises a number of accidents that occurred during aerial application operations.

Read the final report: Collision with a vehicle involving an Air Tractor AT-502B, VH-FNX, 23 km west of Hay, New South Wales, on 17 September 2015

A fatal accident involving an amateur-built aircraft has prompted the ATSB to issue a formal safety recommendation to Australia’s aviation regulator, the Civil Aviation Safety Authority (CASA). The recommendation urges CASA to take action to require builders of amateur-built experimental aircraft to produce a flight manual, or equivalent, for their aircraft following flight testing.

The accident occurred on the afternoon of 10 October 2014, when the pilot of an amateur-built One Design DR-107 aircraft was performing low-level aerobatic manoeuvres. The manoeuvres were being performed to the east of Goolwa Airport, South Australia.

Witnesses described the aircraft performing a series of similar manoeuvres. Each involved a vertical climb and tumbling manoeuvre followed by a vertical dive and a low altitude recovery.

Witnesses reported that, during recovery from the last vertical dive, the aircraft collided with terrain. The aircraft was destroyed by the impact and the pilot was fatally injured.

The ATSB found no evidence of pilot incapacitation or a mechanical fault with the aircraft that could have contributed to the accident. There was insufficient evidence to determine why the recovery was not accomplished above the pilot’s minimum authorised aerobatics height.

CASA recommends that pilots performing low-level aerobatics undertake regular peer reviews due to the high level of skill and fine safety margins involved. The ATSB found no evidence of the pilot undertaking a peer review of their aerobatic performance in the 15 months prior to the accident.

The ATSB identified a safety issue that CASA does not require builders of amateur-built experimental aircraft to produce a flight manual, or equivalent, for their aircraft following flight testing. Without a flight manual, the builder, subsequent owners and other pilots do not have reference to the operational and performance data necessary to safely operate the aircraft.

In response to this safety issue, the ATSB has issued a safety recommendation to CASA to take action to require builders of amateur-built experimental aircraft to produce a flight manual, or equivalent, for their aircraft following flight testing. CASA has 90 days to formally respond to the ATSB’s safety recommendation.

Safety message

This accident highlights the risks inherent in performing low-level aerobatics. Applying the recommendations in CASA civil aviation advisory publication CAAP 155-1(0) Aerobatics will reduce these risks. Specifically, pilots are encouraged to always maintain minimum approved heights above the ground when performing aerobatics and to engage in regular peer reviews.

Owners of amateur-built experimental aircraft are also encouraged to ensure a comprehensive and accurate flight manual, or equivalent, is available for reference by themselves, subsequent owners and other pilots who may fly the aircraft.

Read the final report: Collision with terrain involving One Design DR-107, VH-EGT, Goolwa Airport, South Australia, on 10 October 2014